How to Take Vital Signs

Preparation

• Gather necessary supplies:
  • Stethoscope with blood pressure cuff
  • Thermometer
  • Pulse oximeter
  • Watch
  • Gloves
  • Disinfectant wipes
• Perform hand hygiene and don appropriate PPE when necessary.

Collecting Vital Signs

• Components:
  • Blood pressure
  • Heart rate
  • Respirations
  • Temperature
  • Pain rating (5th vital sign)
  • Oxygen saturation

Procedure

Initial Steps

1. Introducing Yourself:
   • Greet the patient and explain the procedure.
   • Verify patient identity using armband and birthdate.

Pain Assessment

• Ask for pain level using a 0-10 numerical scale.
• Document pain location and description if pain is present.

Oxygen Saturation

• Use a portable probe on the nail bed for reading.
• Ensure fingers have good circulation.
• Document and sanitize the probe after use.

Temperature Measurement

• Can be measured orally, via the forehead (temporal), ear (tympanic), rectally, or axillary.
• Remember:
  • Rectal/Tympanic: 1 degree higher than oral
  • Axillary/Temporal: 1 degree lower than oral
• Ensure probe contact with skin and document the route of measurement.

Pulse Measurement

• Use radial artery (below thumb at wrist).
• Use first three fingers to check pulse.
• Count pulse for 30 seconds if regular, 1 minute if irregular.
• Grade pulse on a scale (0: absent, 1: weak, 2: normal, 3: bounding).

Respirations

• Monitor breathing without alerting the patient.
• Count breaths for 30 seconds if regular, 1 minute if irregular.
• Record rate, depth, and rhythm.

Blood Pressure

• Ensure patient is seated, arm at heart level, legs uncrossed.
• Use correct cuff size.
• Palpate brachial artery, inflate cuff to estimate systolic pressure.
• Inflate cuff 30 mmHg above estimated systolic to avoid missing auscultatory gap.
• Record systolic and diastolic readings.
• Document the arm used and clean the cuff.

Normal Vital Signs

• Heart Rate: 60-100 bpm
• Respirations: 12-20 breaths per minute
• Blood Pressure:
  • Normal: Systolic <120, Diastolic <80
  • Elevated: Systolic 120-129, Diastolic <80
  • Hypertension Stage 1: Systolic 130-139, Diastolic 80-89
  • Hypertension Stage 2: Systolic ≥140, Diastolic ≥90
• Oxygen Saturation: 95-100%
• Temperature:
  • Normal: 97-99°F
  • Fever: >100.4°F

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Remember to document all findings and clean used equipment to prevent contamination.